Quality statement 6: Spinal injections

Quality statement

Young people and adults do not have spinal injections for low back pain without sciatica with the exception of radiofrequency denervation for people who meet the criteria.

Rationale

Spinal injections for treating low back pain without sciatica are not clinically or cost effective, except for people who meet the criteria for a procedure called 'radiofrequency denervation'. To determine whether these people will benefit from this procedure, they may be offered a diagnostic block of the nerves that supply the joints between the vertebrae. If they experience significant pain relief they may then be offered radiofrequency denervation in an attempt to achieve longer-term relief.

Quality measures

Structure

Evidence of local arrangements to ensure that spinal injections are not given to young people and adults to treat low back pain without sciatica, with the exception of radiofrequency denervation for people who meet the criteria.

Data source: Local data collection, for example, service protocols.

Process

Proportion of young people and adults who have spinal injections for low back pain without sciatica who meet the criteria for radiofrequency denervation.

Numerator – the number in the denominator who meet the criteria for radiofrequency denervation.

Denominator – the number of young people and adults who have spinal injections for low back pain without sciatica.

Data source: Local data collection, for example, patient notes.

What the quality statement means for different audiences

Service providers (such as hospitals) have systems in place to make staff aware that spinal injections for low back pain without sciatica should not be performed, with the exception of radiofrequency denervation for people who meet the criteria.

Healthcare professionals (such as physicians, surgeons and radiologists) do not give young people and adults spinal injections for low back pain without sciatica, with the exception of radiofrequency denervation for people who meet the criteria.

Commissioners (such as clinical commissioning groups and NHS England) specify in contracts that services that treat young people and adults with low back pain without sciatica do not perform spinal injections, with the exception of radiofrequency denervation for people who meet the criteria.

Young people and adults with low back pain without sciatica do not have spinal injections with the exception of the procedure of 'radiofrequency denervation' for people who meet the criteria. To check whether the procedure is suitable for the person, an anaesthetic is injected to temporarily block some of the nerves in the spine. If the pain is significantly reduced, the nerves are permanently sealed off using heat (radiofrequency ablation). This stops them from transmitting pain signals.

Source guidance

Low back pain and sciatica in over 16s (2016) NICE guideline NG59, recommendations 1.3.1, 1.3.2 and 1.3.3.

Definitions of terms used in this quality statement

Spinal injections

These are injected agents which aim to either reduce inflammation in tissues (for example, steroid injections), induce inflammation to stimulate healthy tissue regrowth (for example, prolotherapy) or reduce firing of nerve fibres that may be contributing to pain (for example, local anaesthetic). However, medial branch block injections can be used as a diagnostic tool to establish whether the person is likely to respond to radiofrequency denervation.

[Adapted from NICE's guideline on Low back pain and sciatica in over 16s with expert opinion]

Radiofrequency denervation

The procedure called 'radiofrequency denervation' involves sealing off some of the nerves to the joints of the spine to stop the nerves transmitting pain signals. It aims to achieve longer-term pain relief in people with low back pain who experience significant but short-term relief after a diagnostic block by injection of local anaesthetic.

[Adapted from NICE's guideline on Low back pain and sciatica in over 16s with expert opinion]

Criteria

Referral for assessment for radiofrequency denervation for people with chronic low back pain should be considered using the following criteria:

  • non-surgical treatment has not worked for them and

  • the main source of pain is thought to come from structures supplied by the medial branch nerve and

  • they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.

Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.

[Adapted from NICE's guideline on low back pain and sciatica in over 16s, recommendations 1.3.2 and 1.3.3 with expert opinion]